Main Compartment
Epi 1mg 1:10,000 Pre-Filled
Atropine 1mg Pre-Filled
2% Lidocaine pre-filled 100mg
Dextrose 50%
Dextrose 25%
Sodium Bicarbonate 50mEq
Etomidate 20mg
Oral Glucose 15 grams
Pre-Mix Lidocaine 4mg/ml
1000ml NS IV
250ml NS IV
50 ml D5W
Dial a drip
60gtt/cc IV Sets
Macrodrip IV Set
10 cc Syringes
Nebulizer
Sharps Container
Seal number here if applicable
Small drug box
Adenosine 6mg
Diltiazem 25mg
Lopressor 5mg
Procainimide 1gram
Amiodarone
Vasopressin 20units
Calcium Chloride
Magnesium Sulfate 1gm
Narcan 2mg
Phenergan 25mg
Diphenhydramine 50mg
Haldol 5mg
Thiamine 100mg
Epinephrine 1:1,000 1mg
Furosemide 100mg
Baby ASA 81mg/ea (8 minimum)
Nitroglycerin 0.4mg (6 minimum)
Epinephrine 1:1,000 30ml
Dopamine 400mg
Atrovent 0.5mg
Vecuronium 10mg
Succinylcholine 200mg
Glucagon 1mg
Albuterol 2.5mg
Seal number here if applicable
Comments:
Please check this box if you have an immediate issue with your ambulance that needs attention by the management team. The comments
box will be sent by email.
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Airway Management
Pair of Goggles or Glasses
Adult and Pediatric Handle
ea. Miller blades 0-4
ea. Mac blades 1-4
Grandview - Adult
ea. 2.5, 3.0, 3.5, 4.0, 4.5, 5.0, 5.5, 6.0, 6.5, 7.0, 7.5, 8.0, Endotracheal
tubes
ea. Adult Magill Forceps and Pediatric Magill Forceps
10cc Syringes
Adult Thomas Tube Holder
Surgi Lube
Adult Stylettes
Pediatric Stylette
Gum Elastic Bougie
Red and yellow King LTD Airway
Meconium Aspirator with 3 - 3.5 ETT's
SURGICAL AIRWAY KIT
Right Compartment
Controlled Substance Box
Seal Number
Expiration date
IV Supplies
1cc Syringes,
5cc Syringes,
10cc Syringes,
14g 2" IV Catheters,
ea. 14g Catheters, 16g Catheters, 18g Catheters, 20g Catheters
ea. 22g Catheters, 24g Catheters
Alcohol Preps
2x2 Gauze Pads
ea. Saline Locks, Saline Flushes
1" Clear Tape,
Tourniquets
IV Start Sets
ea. Ports,Caps,Butterflies,Tegaderms
ea. 25g needles, 21g needles, 18g needles
Glucometer Kit with a minimum of 3 test strips and lancets
EZ IO Kit (Driver, 3 needles)
Pediatric IO Kit (with Braselow)
Top Cover Pouch
ea. CPAP Circuit, CPAP Generator, Set of O2 Connectors, 10cm peep
Lifepak 12
Adult Fast Patches
Pediatric Fast Patches
Adult Electrodes
Razors
ea. Ped Electrodes and Paper
CO2 Sensor
Spare LP12 batteries
Which vehicle are you in?
What is your employee number?
What is your partners employee number?
Was your ambulance clean at the beginning of shift?
Is there a gas card in your ambulance?
Did you complete a user test?
Did you do a defibrillator shock test?
Shock test at
Shock test Successful?
By submitting this form you're affirming that you have completed an entire
check of your supplies and equipment.
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